In case of spinal cord injury there is a continuous debate in the literature about operative versus non operative treatment and there are strong adovcates on either side. Because of complex nature of spinal injuries and multiple factors affecting prognosis there are options of treatment available which needs to be individualized in every case.
Broadly speaking, there are two kinds of treatments – non operative and operative.
Before we discuss them further a look into pathophysiology of the cord injury is necessary to grasp the concepts.
Cord Changes After Injury
Injury to the cord is of two types
Primary Injury
It is the actual injury that has occured during the process of trauma and could be a contusion or laceration or transection depending upon the severity of insulting trauma.
Secondary Injury
It occurs due to cellular changes at the injury site, and the effects of ongoing neural compression.
While the first kind is not modifiable except to preventive methods, there is need for an effective agent which would prevent secondary injury.
One of the such agents is the methylprednisolone given in in the immediate postinjury phase. Few studies have suggested good improvement but there are studies which found no such evidence.
Opertive Versus Non Operative Treatment
It seems logical that an ongoing compression should be relieved by surgery but this again is controversial because therer is not enough evidence on this.
Moreover, equally effective neural recovery has been demonstrated by few authors with conservative management. It has been observed that bony remodeling reduces residual canal compromise by more than 50% over the course of 1 year, making surgical treatment unnecessary in many patients.
It is however very clear that the late decompression, once natural recovery has ended, is associated with further improvement in neural function.
It must be noted that animal studies have demonstrated benefit of early and late decompression.
Incomplete neural deficit is a relative indication for surgery and should be considered on patient to patient basis.
In spite of every other factor, a persistent neural compression can inhibit neurologic recovery, and decompression can provide dramatic neurologic improvement in many patients.
Non Operative Treatment
Non operative treatment consists of bed rest, brace, molded orthosis or casts. It is estimated that only 20 to 30% of spine fractures require surgery and rest of them can be treated nonoperatively.
Single-column injuries like compression fractures, laminar fracture, and spinous process fractures can be treated with a brace which provides normal normal spinal alignment and immobilizes it.
Two-column injuries are quite unstable and should be treated by bed rest or hyperextension casting.
Operative Treatment
Operative treatment offers immediate spinal stability which allows early sitting by the patient, easy transfer of the patient and earlier rehabilitation.
Moreover, there is better restoration of spinal alignment and correction of translational deformities which translates into restoration of canal dimensions more.
Operative treatment includes decompression of the spinal cord/nerve roots, fixation of the injured spine followed and fusion of the spine.
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